Prostate

Cancer

What is
Prostate
Cancer?
Let us
explain it
to you.

ESMO Patient Guide Series

based on the ESMO Clinical Practice esmo.org
Guidelines
Prostate cancer

Prostate cancer
An ESMO guide for patients
Patient information based on ESMO Clinical Practice Guidelines
This guide has been prepared to help you, as well as your friends, family and caregivers, better understand
prostate cancer and its treatment. It contains information on the causes of the disease and how it is
diagnosed, up-to-date guidance on the types of treatments that may be available and any possible side effects
of treatment.
The medical information described in this document is based on the ESMO Clinical Practice Guideline for
prostate cancer, which is designed to help clinicians with the diagnosis and management of prostate cancer. All
ESMO Clinical Practice Guidelines are prepared and reviewed by leading experts using evidence gained from the
latest clinical trials, research and expert opinion.
The information included in this guide is not intended as a replacement for your doctor’s advice. Your
doctor knows your full medical history and will help guide you regarding the best treatment for you.

Words highlighted in colour are defined in the glossary at the end of the

document. This guide has been developed and reviewed by:

Representatives of the European Society for Medical Oncology (ESMO):
Alan Horwich; Jennifer Lamarre; Claire Bramley; Svetlana Jezdic; and Jean-Yves
Douillard
Representatives of the European Oncology Nursing Society (EONS):
Villa Giulia; Erik Van Muilekom; and Anita Margulies
Representatives of Europa Uomo:
John Dowling; and André Deschamps
Representatives of the European Cancer Patient Coalition (ECPC):
Ken Mastris; AnnaRek; and Lydia Makaroff

2
 WHAT’
ESMO Patients
Guide
S
INSIDE

2 An ESMO guide for patients

4 Prostatecancer: A summary of key information
6 What is the prostate?
7 What is prostate cancer?
9 What are the symptoms of prostate cancer?
10 How common is prostate cancer?
12 What causes prostate cancer?
13 How is prostate cancer diagnosed?
14 How will my treatment be determined?
16 What are the treatment options for prostate cancer?
20 What are the treatment options for localised prostate cancer?
24 What are the treatment options for locally advanced prostate
cancer?
26 What are the treatment options for metastatic prostate cancer?
28 What are the treatment options for prostate cancer that
returns after treatment?
29 Prostate cancer in younger patients
30 Clinical trials
31 Supplementary interventions
33 What are the possible side effects of treatment?
39 What happens next?
42 Support groups
43 References
44 Glossary

3
Prostate cancer

Prostate cancer: A summary of key information

Introduction to prostate cancer
• Prostate cancer forms in the cells of the prostate gland. Many prostate cancers grow slowly and
are not likely to spread, but some can grow more quickly.
• The exact causes of prostate cancer are not known, and in its early stages, prostate cancer often has
no symptoms.
• Prostate cancer is the second most common cancer in men worldwide and mostly affects older men
– more than half of prostate cancers occur in men over the age of 70 years.

Diagnosis of prostate cancer

• Early prostate cancer typically has no symptoms. Symptoms that may appear as the cancer progresses
are often caused by the cancer pressing on the urethra, such as increased frequency in passing urine,
and difficulty or urgency in passing urine.
• A diagnosis of prostate cancer is usually based on the results of clinical examination of the prostate,
a blood test to check levels of a protein called prostate-specific antigen (PSA) and a biopsy.
• Further investigations can help to determine how advanced the cancer is. For example, scans called
magnetic resonance imaging (MRI), positron emission tomography (PET) and computed
tomography (CT) scans may be used to see how far the cancer has spread. Lymph nodes in the
pelvis may also be removed and examined to check if they contain cancer cells.
• Prostate cancer is ‘staged’ according to tumour size, whether it has spread to the lymph nodes and
whether it has spread into the bones or to other parts of the body. This information is used to help
decide the best treatment.

Treatment options for prostate cancer

• Treatment for prostate cancer depends on the size, location and stage of the tumour.
• Patients should be fully informed and involved in decisions about treatment options.
• For some patients, especially elderly men with slow-growing prostate cancer, treatment may not be
appropriate or necessary – this is because they are more likely to die from old age or causes other than
prostate cancer, and therefore the negative side effects from treating the cancer may outweigh any
benefits in life expectancy.
• Treatment approaches for prostate cancer include active surveillance (in which the cancer is closely
monitored and then treated as soon as it progresses), surgery, radiotherapy, hormone therapy
(e.g. androgen deprivation therapy, anti-androgens or testosterone synthesis blocker) and
chemotherapy.

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 ESMO Patients Guide

Localised prostate cancer

• Localised prostate cancer is defined as low risk, intermediate risk or high risk.
• Patients with low-risk disease might receive active surveillance, radical prostatectomy
(surgical removal of the prostate gland) or radiotherapy, which is given either as external
beam radiotherapy or brachytherapy.
• Patients with intermediate-risk disease might receive active surveillance, radical
prostatectomy or
radiotherapy with or without neoadjuvant and concurrent androgen deprivation therapy.
• Patients with high-risk disease might be treated with radical prostatectomy with pelvic
lymphadenectomy (removal of the pelvic lymph nodes) or radiotherapy to the prostate and
lymph nodes with neoadjuvant and concurrent androgen deprivation therapy and adjuvant
androgen deprivation therapy too.

Locally advanced prostate cancer

• Locally advanced disease is usually treated with a radical prostatectomy plus pelvic
lymphadenectomy or radiotherapy with neoadjuvant androgen deprivation therapy and
possibly adjuvant androgen deprivation therapy too.

Metastatic prostate cancer

• Metastatic disease is typically treated with androgen deprivation therapy, either alone or
in combination with the testosterone synthesis blocker abiraterone or chemotherapy.
• If the cancer continues to grow despite treatment with androgen deprivation therapy (also referred to
as castration-resistant prostate cancer [CRPC] or hormone-refractory prostate cancer
[HRPC]), then chemotherapy, the anti-androgen drug enzalutamide or abiraterone may be used.
• Radium-223, denosumab, zoledronic acid or palliative radiotherapy can be used to
treat complications from bone metastases.

Recurrent prostate cancer

• Radiotherapy, androgen deprivation therapy or radical prostatectomy may be used to
treat a
recurrence.

Follow-up during/after treatment

• The timings of follow-up appointments vary between regions and practices. Typical follow-up appointments
include a blood test to monitor PSA levels, clinical examination and scans.
• Patients receiving long-term hormone therapy may have MRI scans to monitor the cancer and
bone scans to check for osteoporosis.
• The treatments for prostate cancer can have long-term side effects that may impact the patient’s life
for years after diagnosis.
• Support groups can help patients and their families to better understand prostate cancer, and to learn
how to cope with all aspects of the disease, from diagnosis to long-term physical and emotional effects.

5
Prostate cancer

What is the prostate?

The prostate is a small, walnut-sized gland that lies at the base of the bladder in men. It consists of two
symmetrical lobes and surrounds the first part of the tube (the urethra) that carries urine from the bladder to
the penis. The urethra also carries semen, which is the fluid containing sperm.
The prostate is coloured orange in the diagram.

Anatomy of the male reproductive organs, showing the position of the

prostate.

6
 ESMO Patients Guide

What is prostate cancer?

Prostate cancer is a cancer that forms in the cells of the prostate gland. Most prostate cancers begin in
the cells that line the prostate gland – these cancers are known as acinar adenocarcinomas. Many of
these cancers grow extremely slowly and are not likely to spread, but some can grow more quickly.

Prostate cancer is often a slow-growing cancer

with few symptoms

What are the different types of prostate cancer?

There are five main categories of prostate cancer:
• Acinar adenocarcinoma: This is the most common
type of prostate cancer, accounting for around 90%
of cases. Acinar adenocarcinoma develops in the
outer gland cells of the prostate.
• Ductal adenocarcinoma: This type of prostate
cancer develops in the cells that line the
ducts (or tubes) of the prostate gland.
Ductal
adenocarcinoma tends to grow more quickly
than acinar adenocarcinoma.
• Transitional cell (or urothelial) cancer: This cancer
develops in the cells of the urethra. It typically begins in the bladder and spreads to the prostate,
but rarely it can begin in the prostate and spread into the bladder and nearby tissues.
• Squamous cell cancer: This type of cancer develops from flat cells that cover the prostate, and tends
to grow more quickly than adenocarcinomas.
• Small cell cancer: This is a type of neuroendocrine cancer made up of small round cells, which is also
sometimes called oat cell cancer. Small cell prostate cancer is very rare, accounting for less than 2% of
all cases of prostate cancer.

7
Prostate cancer

Prostate cancer is classified by how advanced the disease is:

Localised prostate cancer

Localised prostate cancer means that the cancer is completely contained within the prostate gland and
has not spread anywhere else in the body. Localised prostate cancer is further divided into three risk
groups, depending on how likely it is that the cancer will grow and spread:
• Low-risk prostate cancer: Unlikely to grow or spread for many years.
• Intermediate-risk prostate cancer: Unlikely to grow or spread for a few years.
• High-risk prostate cancer: Might grow or spread within a few years.

Localised prostate cancer is categorised into

low-, medium- and high-risk cancer

Locally advanced prostate cancer

Prostate cancer is described as locally advanced if the cancer has spread beyond the prostate gland.
For example, the cancer may have spread into the tissue around the prostate, the seminal vesicles,
nearby organs such as the rectum, or nearby lymph nodes.

Metastatic prostate cancer

Metastatic prostate cancer means that a cancer that began in the prostate has spread to another part of
the body. Tumours found in other parts of the body away from the prostate are called metastases.
Prostate cancer most commonly spreads to lymph nodes in other parts of the body or to the bones, but can
also spread to other organs.
Prostate cancer is also classified according to its grade. The grade of a cancer tells us how much the cancer
cells look like normal cells, and can give the doctor an idea of how aggressive the cancer is and what
treatment is needed.
The Gleason score system is used to grade prostate cancer. Several samples of cells (biopsies) from the
prostate are examined and a pathologist grades each sample from 1 to 5. Grades 1 and 2 are normal
prostate cells. Grades 3–5 are cancer cells, with grade 5 being the most abnormal. The pathologist works
out an overall Gleason score by adding together the two most common Gleason grades in the samples. For
example, if the most common grade is grade 3, and the second most common is grade 4, then the overall
Gleason score is
7. Typical Gleason scores in prostate cancer range from 6 to 10. The higher the Gleason score, the
more likely it is that the cancer will grow and spread quickly.

The Gleason score indicates how aggressive

the prostate cancer is

8
 ESMO Patients Guide

What are the symptoms of prostate

cancer?
In its early stages, prostate cancer often has no
symptoms. As the cancer progresses and the prostate
becomes enlarged, symptoms that may be experienced
include:
• Passing urine more frequently during the day and/or
night.
• Difficulty passing urine.
• Urgency to pass urine.
• Leaking urine.
• Blood in the urine or semen.
• Erection problems.
Prostate cancer often has no
symptoms in its early stages

You should see your doctor if you experience any of these symptoms. However, it is important to remember
that these symptoms are common in people who do not have prostate cancer; they may also be caused by
other conditions. For example, benign prostatic hyperplasia is caused by enlargement of the prostate
gland. Benign prostatic hyperplasia does not usually develop into cancer, but can have similar
symptoms to prostate cancer as a result of the enlarged prostate gland pressing on the urethra.

Screening for prostate cancer

Prostate-specific antigen (PSA) is a protein that is produced by normal cells and by cancerous prostate
cells. It is normal for all men to havesome PSA in their blood, but a high level of PSA can be a sign of
prostate cancer. Routine testing (or screening) of PSA levels in men who do not have any symptoms of
prostate cancer is not recommended. This is because large studies have shown that although this type of
screening can reduce the number of deaths from prostate cancer, it also leads to many men being falsely
diagnosed and treated for prostate cancer. However, PSA testing may be useful in certain groups of people,
for example men who have a family history of prostate cancer.

There is currently no routine screening

programme for prostate cancer in the general
population

9
Prostate cancer

How common is prostate

cancer?

Prostate cancer is most common in older

men

Prostate cancer mostly affects older men – more than half of prostate cancers occur in men over the age of
70 years. Prostate cancer is the second most common cancer in men worldwide. The highest incidences of
prostate cancer are reported in Australia/New Zealand, North America, and Northern and Western Europe.
The lowest incidences are in Eastern and South Central Asia and Northern Africa. The large geographic
variation in prostate cancer rates is probably due to differences in the availability of testing and diagnosis
(Ferlay et al., 2013).

10
 ESMO Patients Guide

The map shows estimated numbers of new cases of prostate cancer diagnosed in 2012 (the most recent statistics available)
per 100,000 people of each region’s population (Ferlay et al., 2013).
NORTHERN EASTERN ASIA
AMERICA CENTRAL AND
97. WESTERN EASTERN 10.
EUROPE EUROPE
2 85.8 31.3 5

NORTHERN SOUTH EASTERN

CENTRAL SOUTHERN EUROPE ASIA
AMERICA EUROPE
28. 58. 85. 11.
4 6 0 MELANESIA
2
22.
7

SOUT
H CENTRAL
ASIA
CARRIBEAN
4.5
AUSTRALI
79.8 A/ NEW
ZEALAND
SOUTH WESTERN 111.
AMERICA AFRICA
60.1 25.1 WESTERN 6
ASIA

MIDDLE
28.0 MELANESIA
AFRICA
27.0 EASTERN 22.
AFRICA
23. 7
SOUTHERN
POLYNESIA
AFRICA
3
61. 81.
7 NORTHERN
AFRICA 9
10.
6
11
Prostate cancer

What causes prostate

cancer?
The causes of prostate cancer are not known, but
several risk factors for developing prostate cancer
have been identified. It is important to remember that
having a risk factor increases the risk of cancer
developing but it does not mean that you will definitely
get cancer. Likewise, not having a risk factor does not
mean that you definitely won’t get cancer.

The precise causes of prostate cancer

are not known

FACTORS THAT MAY INCREASE RISK

Increasing age

Ethnicity – prostate cancer is more common in Black-African men than

in White men, and least common in Asian men
Family history of prostate cancer

Being overweight

Being tall

Hormone levels – a high level of a hormone called insulin-like

growth factor 1 (IGF-1) is associated with an increased risk of
prostate cancer
Inflammation of the prostate

Exposure to cadmium

There are various risk factors associated with developing prostate cancer although each factor may not apply to every
man who develops the disease.

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 ESMO Patients Guide

How is prostate cancer diagnosed?

A diagnosis of prostate cancer is based on the results of the following examinations and tests:

Clinical examination
If you have symptoms of prostate cancer, your doctor may carry out a clinical examination to feel your
prostate gland. This examination is called a digital rectal examination. He/she will put a gloved finger
into your rectum in order to feel the prostate gland and check for any abnormalities.

PSA blood test

Your doctor may recommend that you have a PSA test
to check the levels of PSA in your blood; however, it
is
important to understand that high levels of PSA can also
be caused by non-cancerous conditions, and a PSA test
on its own cannot diagnose prostate cancer.

Clinical examination and a PSA test

can indicate if prostate cancer
might be present, but further tests
are needed for a definite diagnosis

Biopsy
Based on the results of the digital rectal examination and PSA tests, your doctor may recommend that
you have a biopsy. This involves taking samples of tissue from the prostate gland to look for cancer
cells.
A procedure called transrectal ultrasound scan guided (TRUS) biopsy is typically used to diagnose
prostate cancer. Local anaesthetic is injected into the rectum to make the procedure as comfortable as
possible. A small ultrasound scanner is inserted into the rectum and produces sound waves to create a
clear picture of the prostate gland. A fine needle is then used to take at least 10–12 samples of tissue from
the prostate gland. If you undergo a TRUS biopsy, your doctor will give you antibiotics to prevent
infection developing after the biopsy (Parker et al., 2015).
If the TRUS biopsy shows no signs of cancer but your doctor still suspects that you may have cancer, he/she
may recommend that you have a magnetic resonance imaging (MRI) scan, which uses magnetic fields
and radio waves to produce detailed images of the inside of the body, or additional biopsies via the
perineum (the skin behind the testicles).

A prostate biopsy is carried out to confirm

the presence of prostate cancer

13
Prostate cancer

How will my treatment be determined?

Your treatment will depend on the staging of your cancer and risk assessment.

Staging
Staging of the cancer is used to describe its size and position and whether it hasspread from where it started. To
gather this information, your doctor may wish to carry out an MRI scan, a positron emission tomography
(PET) scan, a computed tomography (CT) scan, pelvic node dissection and/or a bone scan (Parker et al.,
2015).

• MRI scan: MRI uses magnetic fields and radio waves to produce detailed images of the inside of your
body.
• PET scan: PET uses a radioactive substance injected into a vein and can help find areas of cancer
that an MRI or CT scan may miss. Most PET scans are now performed along with a CT scan.
• CT scan: This is a type of x-ray technique that lets doctors see your internal organs in cross-section.
• Pelvic node dissection: This is a procedure to remove pelvic lymph nodes to check if they
contain cancerous cells.
• Bone scan: This is a scan to look for bone metastases and involves a small amount of radioactive
substance injected into a vein to allow doctors to see abnormal areas of bone across your whole body,
as abnormal bone absorbs more radioactivity than healthy bone.

After diagnosis, imaging scans can show

how far advanced the prostate cancer
is

Staging to determine the size and spread of the cancer is described using a sequence of letters and numbers.
For prostate cancer, there are four stages designated with Roman numerals I to IV. Generally, the lower the
stage, the better the outcome (or prognosis) for the patient. TheTNM staging system considers:
• How big the cancer is, or tumour size (T).
• Whether the cancer has spread to lymph nodes (N).
• Whether it has spread to distant sites, or metastases (M).

Staging helps to determine the most appropriate

treatment for prostate cancer

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 ESMO Patients Guide

The stage grouping system for prostate cancer is described in the table below (Parker et al., 2015). This may
seem complicated but your doctor will be able to explain which parts of this table correspond to your cancer.

Stage I. T • Clinically inapparent tumour neither palpable nor visible by imaging (T1)
Cancer is confined to half of • Tumour involves one half of one lobe or less (T2a)
one side of the prostate, or N • No regional lymph node metastasis (N0)
less (T1-N0-M0 or T2a-N0-
M • No distant metastasis (M0)
M0)

Stage II. T • Tumour involves more than one half of one lobe but not both lobes (T2b)
Cancer is in more than • Tumour involves both lobes (T2c)
half of one side of the N • No regional lymph node metastasis (N0)
prostate,
M • No distant metastasis (M0)
but is still contained within
the prostate gland (T2b-N0-
M0
or T2c-N0-M0)

Stage III. T • Tumour extends through the prostate capsule (T3)

Cancer has broken through the N • No regional lymph node metastasis (N0)
covering of the prostate gland M • No distant metastasis (M0)
and may have spread into the
seminal vesicles (T3-N0-M0)
Stage IV. T • Tumour is fixed or invades adjacent structures other than
Cancer has spread into nearby seminal vesicles, such as external sphincter, rectum,
bladder, levator muscles, and/or pelvic wall (T4)
body organs, such as the
rectum or bladder (T4-N0-M0), N • Metastasis in regional lymph node(s) (N1)
to nearby lymph nodes (any M • Distant metastasis (M1)
T-N1-M0),
Stage orsystem
grouping to other
forparts of
prostate
the body outside the pelvis
cancer.
(any T-any N-M1)

15
Prostate cancer

What are the treatment options for prostate cancer?

Your treatment will depend upon the size, location and
stage of the tumour, as well as your general health and
level of fitness. The choice of treatments will be
discussed with you and your preferences will be taken
into account. Your treatment will be discussed by a
multidisciplinary team, which means that experts in
different areas of cancer treatment (e.g. surgeons,
urologists, oncologists, radiotherapists and nurses)
come together to share their expertise in order to provide
the best patient care.
It is important that patients are fully involved in the
treatment decision-making – when there are several treatments available, doctors should involve patients in
making decisions about their care so that the patients can choose the care that meets their needs and
reflects what is important to them. This is called ‘shared decision making’.

It is important that patients are fully involved in

discussions and decisions about their
treatment

When discussing treatment options for your prostate cancer, your doctor will want to weigh up the benefits
to your health and life expectancy against the side effects of treatment. This is very important in prostate
cancer, asmany patients can live a normal life with a slow-growing prostate cancer for a number of years.
For these patients, the side effects from treating the cancer may outweigh any benefits in terms of prolonging
life – they are much more likely to die from old age or causes other than prostate cancer.
Your doctor will be happy to answer any questions you have about your treatment. Three simple questions
that may be helpful when talking with your doctor or any healthcare professional involved in your care are:
• What treatment options do I have?
• hat are the possible advantages and disadvantages of these options?
• How likely am I to experience these advantages and disadvantages?
Your doctor may recommend one or more of the following approaches for managing prostate cancer.

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 ESMO Patients Guide

Active surveillance
Active surveillance involves close monitoring of the cancer, with no immediate treatment. Active
surveillance aims to avoid unnecessary treatment, which may cause unpleasant side effects, and is an
option for men with low- or intermediate-risk localised prostate cancer (Parker et al., 2015). During active
surveillance, doctors may regularly check your blood PSA levels and carry out prostate biopsies or
MRI scans. If the cancer starts to grow, your doctor will recommend a suitable curative treatment.

Watchful waiting
In watchful waiting, your doctor will monitor your cancer with no immediate treatment, but this involves
fewer tests than with active surveillance. Typically, treatment will start if you develop symptoms that
need to be controlled. Watchful waiting is an option for men with low-risk localised disease and for
men with
localised or locally advanced disease who are not suitable for curative treatments (Parker et al., 2015). The
aim of watchful waiting is to manage, rather than cure, the cancer.

There is often no immediate treatment for

prostate cancer, especially if the cancer is
slow-growing

Surgery
Some men with prostate cancer will have an operation
to remove the prostate gland – this operation is
called a radical prostatectomy. The aim of a
radical prostatectomy is to cure the cancer by
completely
removing the tumour. The surgeon removes the prostate
gland as well as the surrounding tissues, lymph nodes
and seminal vesicles. This is usually done by making a
cut into your abdomen, but some patients may be offered
keyhole surgery.
Nerve-sparing prostatectomy is a type of surgery
that involves the removal of the prostate tissue without removing the nerves that control erections. This
type of surgery can reduce the risk of erection problems after surgery, but is only possible when the cancer
is not growing close to the nerves.
Radical prostatectomy is a curative treatment option for patients with localised or locally advanced
prostate cancer (Parker et al., 2015). It is important to understand that radical prostatectomy is major surgery
with many possible side effects. This type of surgery may not be suitable for men with slowly growing
prostate cancer as they may be more likely to die of old age or causes other than prostate cancer.
Other types of surgery may also be used in the treatment of prostate cancer. For example, removal of the
inner part of the prostate (also called transurethral resection of the prostate) or removal of the
testicles can relieve symptoms or help control the spread of the cancer. However, these types of surgery are
not curative.

17
Prostate cancer

Radiotherapy
Radiotherapy uses ionising radiation to damage the DNA of cancerous cells, causing them to die.
Two types of curative radiotherapy may be used to treat prostate cancer:
• External beam radiotherapy directs radiotherapy to the cancer from a machine outside the
body.
• Brachytherapy directs radiotherapy to the cancer from a radioactive source placed inside the
prostate gland.
Radiotherapy is a recommended treatment option for men with localised or locally advanced
prostate
cancer.

Surgery to remove the prostate gland

or radiotherapy can cure prostate
cancer

Hormone therapy
Testosterone is a hormone made mainly by the
testicles. Prostate cancer needs testosterone to
grow, so hormone therapies that block the actions
of testosterone are used to reduce the risk of
prostate cancer coming back after treatment with
surgery or radiotherapy, and to slow the growth of
advanced
prostate cancer. On its own, hormone therapy is
not a
curative treatment.
There are three main types of hormone therapy used
in the treatment of prostate cancer:
• Androgen deprivation therapy works by stopping the testicles from producing testosterone.
These drugs are given by injection or implant. There are two types of androgen deprivation
therapy: luteinising hormone-releasing hormone agonists (e.g. leuprorelin, goserelin,
buserelin, triptorelin) and gonadotrophin-releasing hormone antagonists (e.g. degarelix)
• Anti-androgens (e.g. bicalutamide, flutamide, enzalutamide) are tablets that prevent
testosterone
from reaching the cancer cells.
• Abiraterone is a new type of hormone therapy tablet that blocks testosterone synthesis. A steroid
is taken alongside abiraterone to lower the risk of side effects.
Hormone therapy can effectively manage
prostate cancer but is not a curative
treatment

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 ESMO Patients Guide

Chemotherapy
Chemotherapy destroys cancer cells. Chemotherapy (e.g. docetaxel, cabazitaxel) may be used
to treat some patients with metastatic prostate cancer (Parker et al., 2015). A steroid is taken
alongside chemotherapy to make it more effective and lower the risk of side effects.

Other therapies
Other treatments for prostate cancer include drugs to treat the effects of bone metastases,
including
radium-223, denosumab and zoledronic acid (Parker et al., 2015).

19
Prostate cancer

What are the treatment options for localised

prostate cancer?
Localised prostate cancer is categorised into three risk groups, which are defined by the size of the
tumour (T), the grade of the cancer (Gleason score) and PSA levels. Your doctor will be able to tell you
which risk group applies to you. This is important because the treatment for localised prostate cancer
varies according to the risk group.

Low risk T1–T2a and Gleason score <6 and PSA <10

Intermediate risk T2b and/or Gleason score 7 and/or PSA 10–20

High risk ≥T2c or Gleason score 8–10 or PSA >20

Risk groups for localised prostate cancer.

It is important to understand that there is no single standard treatment for localised prostate cancer. A
number of treatment options are available for each risk group, and your doctor will fully discuss these with
you.

Treatment for localised prostate cancer

depends on the risk group of the
cancer

Active surveillance
Active surveillance is an option for men with low- or intermediate-risk localised disease (Parker et al.,
2015). The cancer is closely monitored and further treatment is considered if the cancer progresses.

Surgery
The aim of surgery is to remove the cancer as well as
a healthy margin of tissue around it. After the
operation, the removed tissue is examined under a
microscope
to check that all of the cancer was removed. Radical
prostatectomy may be used to treat low- or intermediate-
risk localised disease. If there is evidence that the
cancer may have spread to the lymph nodes, then
pelvic node dissection might also be carried out. High-
risk localised disease may be treated with radical
prostatectomy plus pelvic lymphadenectomy, in
which the lymph nodes are removed from the pelvis
(Parker et al., 2015).

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 ESMO Patients Guide

Radiotherapy
Men with low- or intermediate-risk localised disease may receive external beam radiotherapy
or brachytherapy. High-risk localised disease may be treated with external beam
radiotherapy in combination with hormone therapy (Parker et al., 2015).

Hormone therapy
Hormone therapy alone is not recommended as the main treatment for localised prostate cancer, but it
may be used in combination with radiotherapy as neoadjuvant and/or adjuvant therapy for intermediate-
or high-risk disease. Neoadjuvant therapy is a treatment that is given before the main treatment, and
adjuvant therapy is a treatment given after the main treatment.

Hormone therapy may be used in addition to

radiotherapy for some patients with localised
disease

In patients with intermediate-risk localised prostate cancer, neoadjuvant and concurrent androgen
deprivation therapy for 4–6 months may be used in combination with external beam
radiotherapy.
In men with high-risk localised disease, neoadjuvant and concurrent androgen deprivation therapy is
recommended for 4–6 months in combination with external beam radiotherapy, and adjuvant
androgen deprivation therapy may also be administered for 2–3 years after the radiotherapy treatment
if the doctor thinks there is a high risk of death from the cancer (Parker et al., 2015).

Low-risk
localised prostate
cancer

Radiotherapy
Active Radical (external
surveillanc prostatecto beam OR
e my brachytherapy)

Flowchart showing curative treatment approaches for low-risk localised prostate

cancer.

21
Prostate cancer

Intermediate-risk
localised
prostate cancer

Neoadjuvant +
Active Radical
concurrent ADT
surveillanc prostatecto
considered
e my

Radiotherapy
(external beam
OR
brachytherapy)

Flowchart showing curative treatment approaches for intermediate-risk localised prostate

cancer. ADT, androgen deprivation therapy.

High-risk
localised prostate
cancer

Radical prostatectomy + Neoadjuvant +

pelvic lymphadenectomy concurrent
ADT

Radiotherapy
(external beam)

Adjuvant ADT in
patients at high risk
of death

Flowchart showing curative treatment approaches for high-risk localised prostate

cancer. ADT, androgen deprivation therapy.

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 ESMO Patients Guide

Watchful waiting
Some men with localised disease are not suitable for, or may choose not to undergo, the curative
treatments described above. In these patients, watchful waiting may be an appropriate approach, followed
by hormone therapy to treat symptoms if/when they arise.

23
Prostate cancer

What are the treatment options for locally

advanced prostate cancer?

Surgery
Radical prostatectomy plus pelvic lymphadenectomy to remove lymph nodes from the pelvis is
a treatment option for men with locally advanced prostate cancer (Parker et al., 2015).

Radiotherapy
As an alternative to surgery, locally advanced disease can be treated with external beam radiotherapy
in combination with hormone therapy (Parker et al., 2015).

Locally advanced prostate cancer is typically

treated with surgery or radiotherapy

Hormone therapy
Neoadjuvant and concurrent androgen deprivation therapy is typically administered for 4–6 months in
combination with external beam radiotherapy in the treatment of locally advanced prostate cancer,
and adjuvant androgen deprivation therapy may be given for 2–3 years in patients who are thought to be
at high risk of dying from their cancer (Parker et al., 2015).

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 ESMO Patients Guide

Locally advanced
prostate cancer

Radical prostatectomy + Neoadjuvant +

pelvic lymphadenectomy concurrent
ADT

Radiotherapy
(external beam)

Adjuvant ADT in
patients at high risk of
death

Flowchart showing curative treatment approaches for locally advanced prostate

cancer. ADT, androgen deprivation therapy.

Watchful waiting
Some men with locally advanced disease are not suitable for, or may choose not to undergo, the curative
treatments described above. In these patients, watchful waiting may be an appropriate approach, followed
by hormone therapy to treat symptoms if/when they arise.

25
Prostate cancer

What are the treatment options

for metastatic prostate cancer?
The main aims of treatment for metastatic prostate cancer are to
relieve symptoms and improve quality of life.

Metastatic prostate cancer is treatable

Hormone therapy
Androgen deprivation therapy is usually the initial treatment given to men with metastatic prostate
cancer. This may be given alone, in combination with the testosterone synthesis blocker abiraterone or
in combination with chemotherapy (Parker et al., 2015; ESMO Guidelines Committee, 2018).
If the cancer continues to grow despite treatment with androgen deprivation therapy (also referred to as
castration-resistant prostate cancer [CRPC] or hormone-refractory prostate cancer [HRPC]), then the
anti-androgen drug enzalutamide or abiraterone may be used in men with no or few symptoms (Parker et al.,
2015).

Hormone therapy is the main initial treatment

option for metastatic prostate cancer

Chemotherapy
Docetaxel is a chemotherapy drug that may be given
alongside androgen deprivation therapy in men with
metastatic prostate cancer whoare fit enough to tolerate
chemotherapy. Docetaxel is also recommended for
use in men with metastatic disease that has continued to
grow despite treatment with androgen deprivation
therapy.
If the cancer continues to progress after docetaxel
treatment, then the chemotherapy drug cabazitaxel may
be considered, as well as abiraterone, enzalutamide
and Radium-223 (Parker et al., 2015).

26
 ESMO Patients Guide

Other therapies
Radium-223 is a radioactive liquid that is sometimes used to treat patients with bone metastases.
Denosumab and zoledronic acid are drugs that can reduce the bone-related complications of
metastatic disease (e.g. bone pain, bone fracture), and may be recommended for some patients with bone
metastases. External beam radiotherapy can also be used to treat pain from bone metastases
(Parker et al., 2015).

Metastatic
prostate
cancer

ADT+
ADT +
docetaxel AD
abirateron
in fit T
e
patients

Abirateron Enzalutami Radium- Radium-

e in patients de in 223 in 223 in
Docetaxe Docetaxe
with few/no patients with patients with patients with
l l
symptoms few/no bone bone
symptoms metastases metastases

Radium-
223 in
Cabazitaxel Enzalutamide Abiraterone
patients with
bone
metastases

Flowchart showing treatment approaches for metastatic prostate

cancer. ADT, androgen deprivation therapy.

27
Prostate cancer

What are the treatment options for prostate

cancer that returns after treatment?
Despite the best possible treatment at diagnosis, there is still a possibility that your cancer may return.
Cancer that comes back is called a recurrence.

Radiotherapy
Following radical prostatectomy, PSA levels
are monitored closely. If the PSA levels rise,
then
radiotherapy may be given in the prostate area (Parker
et al., 2015).

Hormone therapy
Androgen deprivation therapy may be given to
men who have signs of recurrence following
radical
prostatectomy or external beam radiotherapy (Parker
et al., 2015). In men who have previously been treated with
radiotherapy, radical prostatectomy may be a
treatment option.

Recurrent prostate cancer can be treated with

radiotherapy, surgery and/or hormone
therapy

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 ESMO Patients Guide

Prostate cancer in younger

patients
Prostate cancer diagnosed in men younger than 55 years
often grows more rapidly than prostate cancer in
patients diagnosed at an older age. The reasons for this
difference are not clear, but we know that patients who are
diagnosed at a younger age are less likely to survive the
cancer. If you are a younger man diagnosed with
prostate cancer, your doctor will guide you through all
of your treatment options.

Prostate cancer in younger men can spread more

quickly than in older patients

Prostate cancer treatment can affect fertility – following a radical prostatectomy you will not be able to
ejaculate semen, and radiotherapy and hormone therapy can reduce semen and sperm production. If
you plan to have children in the future, your sperm can be collected and stored before your cancer treatment
begins.

29
Prostate cancer

Clinical trials
Your doctor may ask you whether you would like to take part in a clinical trial. This is a research
study conducted with patients in order to (ClinicalTrials.gov, 2017):
• Test new treatments.
• Look at new combinations of existing treatments
or change the way they are given to make them
more effective or reduce side effects.
• Compare the effectiveness of drugs used to
control symptoms.
• Find out how cancer treatments work.
Clinical trials help to improve knowledge about cancer
and develop new treatments, and there can bemany benefits
to taking part. You would be carefully monitored during and
after
the study and the new treatment may offer benefits over existing therapies. It’s important to bear in mind,
however, that some new treatments are found not to beas good as existing treatments or to have side effects
that outweigh the benefits (ClinicalTrials.gov, 2017).

Clinical trials help to improve knowledge about

diseases and develop new treatments – there can be
many benefits to taking part

Several new drugs for the treatment of prostate cancer arenow entering clinical trials, including
immunotherapy agents, which stimulate the body’s immune system to fight cancer cells.
Pembrolizumab, an immunotherapy drug which blocks a protein called programmed cell death
protein 1 (PD-1) on the surface of some immune cells, has shown encouraging results in some patients
with metastatic prostate cancer (Hansen et al., 2018; de Bono et al., 2018).
Olaparib is a drug that blocks the actions of an enzyme involved in DNA repair. Olaparib is already
used to treat some types of cancer, especially those that have mutations in genes called BRCA1 and
BRCA2.
Olaparib has shown encouraging results in patients with metastatic prostate cancer, both on its own and
in combination with abiraterone (Mateo et al., 2015; Clarke et al., 2018).
You have the right to accept or refuse participation in a clinical trial without any consequences for the
quality of your treatment. If your doctor does not ask you about taking part in a clinical trial and you want
to find out more about this option, you can ask your doctor if there is a trial for your type of cancer taking
place nearby (ClinicalTrials.gov, 2017).

30
 ESMO Patients Guide

Supplementary
interventions
Patients may find that supplementary care helps
them to cope with their diagnosis, treatment and the
long-term effects of prostate cancer

Over the course of disease, anti-cancer treatments should be supplemented with interventions that aim to
prevent the complications of disease and treatment, and to maximise your quality of life. These interventions
may include supportive, palliative, survivorship and end-of-life care, which should all be coordinated by a
multidisciplinary team (Jordan et al., 2018). Ask your doctor or nurse about which supplementary
interventions are available; you and your family may receive support from several sources, such as a
dietician, urinary incontinence nurse, lymphoedema nurse, social worker, priest or occupational
therapist.

Supportive care
Supportive care involves the management of cancer symptoms and the side effects of therapy. This is
particularly important for men with prostate cancer, asmany will live with the disease for a long period of
time.

Palliative care
Palliative care is a term used to describe care interventions in advanced disease, including the
management of symptoms as well as support for coping with prognosis, making difficult decisions and
preparation for end-of-life care. Palliative care in men with metastatic prostate cancer often includes
treatment for pain, diarrhoea, urinary incontinence, nutritional problems, leg swelling and bedsores.

Survivorship care
Support for patients surviving cancer includes social
support, education about the disease and rehabilitation. For
example, psychological support can help you to cope with
any worries or fears. Psychosocial problems impacting
your quality of life may include concerns about sexual,
urinary
or bowel functioning. Patients often find that social support
is essential for coping with the cancer diagnosis,
treatment and the emotional consequences. A survivor
care plan can help you to recover wellbeing in your
personal, professional and social life. For further
information and advice on
survivorship, see ESMO’s patient guide on survivorship (
http://www.esmo.org/Patients/Patient-Guides/Patient- Guide-on-Survivorship).

31
Prostate cancer

End-of-life care
End-of-life care for patients with incurable cancer primarily focusses on making the patient comfortable and
providing adequate relief of physical and psychological symptoms, for example palliative sedation to induce
unconsciousness can relieve severe pain, dyspnoea, delirium or convulsions (Cherny, 2014). Discussions about
end-of-life care can be very distressing, but support should always be available to you and your family at this
time.

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 ESMO Patients Guide

What are the possible side effects of treatment?

As with any medical treatment, you may experience side
effects from your anti-cancer treatment. The most common
side effects for each type of treatment are highlighted below,
along with some information on how they can be managed.
Youmay experience side effects other than those discussed
here. It is important to talk to your doctor about any
potential side effects that are worrying you.
Doctors classify side effects from any cancer therapy
by assigning each event a ‘grade’, on a scale of 1–4,
by increasing severity. In general, grade 1 side effects
are
considered to be mild, grade 2 moderate, grade 3 severe and grade 4 very severe. However, the precise
criteria used to assign a grade to a specific side effect varies depending on which side effect is being
considered. The aim is always to identify and address any side effect before it becomes severe, so you should
always report any worrying symptoms to your doctor as soon as possible.

It is important to talk to your doctor about any

treatment-related side effects that are worrying you

Fatigue is very common in patients undergoing cancer treatment and can result from either the cancer
itself or the treatments. Your doctor can provide you with strategies to limit the impact of fatigue,
including getting
enough sleep, eating healthily and staying active (Cancer.Net, 2017). Loss of appetite and weight loss can also arise
due to the cancer itself or the treatments. Significant weight loss, involving loss of both fat and muscle tissue,
can lead to weakness, reduced mobility and loss of independence, as well as anxiety and depression (Escamilla
and Jarrett, 2016). Your doctor may refer you to a dietician, who can look at your nutritional needs and advise you
on your diet and any supplements that you might need.

Surgery
Following surgery for prostate cancer, you may experience erection problems. This is likely if the surgeon
had to remove nerves during the operation. Some men will be able to have an erection after undergoing
surgery, but this will depend on whether or not the surgeon was able to avoid removing the nerves, whether or
not you were able to have erections before the procedure, and your age. Youmay need to take a drug such as
sildenafil to help you get an erection.
Youmay also have problems controlling the flow of urine (urinary incontinence) after your operation,
resulting in leakage of urine. This can last up to a year after the operation, by which time most men have no
problems or wear a small pad. Your doctor or nurse can refer you to a specialist urinary incontinence clinic
if urine leakage continues to be a problem.

33
Prostate cancer

Lymphoedema can occur in the legs if lymph nodes have been removed. You can reduce your risk of
lymphoedema in several ways:
• Maintain a healthy body weight to reduce the strain on your lymphatic system.
• Exercise regularly to encourage lymphatic drainage.
• Protect your skin to avoid infection.
If you notice any signs of swelling or infection, tell your doctor as soon as possible.

Radiotherapy
The immediate side effects of external beam radiotherapy are usually due to the effects of radiation
on the organs surrounding the prostate gland. Common side effects of radiotherapy include
fatigue,
skin irritation, bladder inflammation, diarrhoea and loss of pubic hair. The main side effects associated
with
brachytherapy include bladder irritation, blood in the urine and blood in the semen.
It is important to look after your skin during radiotherapy treatment to prevent infection and reduce pain.
Let your doctor or nurse know of any symptoms as he/she may be able to help.

Hormone therapy
The common side effects in patients treated with hormone therapy often relate to the reduced action of
testosterone (e.g. loss of sex drive, erection problems, hot flushes, decreased body hair and loss of muscle
bulk). Many of the side effects from hormone therapy can be prevented or managed effectively. Always tell
your doctor or nurse as soon as possible if you notice any side effects from taking hormone therapy. The
table below lists the most common side effects of hormone therapy drugs that may be used in the treatment
of prostate cancer.
THERAPY POSSIBLE SIDE EFFECT HOW THE SIDE EFFECTS MAY BE MANAGED

Abiraterone • Diarrhoea • Let your doctor know if you experience diarrhoea or fluid retention/
(Zytiga SPC, 2017) • Hypertension swelling (oedema) – they will help you to manage these side
• Hypokalaemia effects
• Increased liver enzymes • Your liver function, potassium levels and blood pressure will
• Peripheral oedema be monitored before, during and after treatment
• Urinary tract infection

Bicalutamide • Abdominal pain • Let your doctor know if you experience dizziness, asthenia or
(Bicalutamide SPC, • Anaemia fluid retention/swelling (oedema) – they will help you to
2017) • Asthenia manage these side effects
• Breast tenderness • Gastrointestinal effects such as constipation, nausea
• Constipation and abdominal pain should be reported to your doctor
• Dizziness
• Haematuria • Your doctor may be able to help you cope with hormonal effects
• Hot flushes such as hot flushes and breast tenderness
• Nausea
• Oedema

continued
overleaf
34
 ESMO Patients Guide

THERAPY POSSIBLE SIDE EFFECT HOW THE SIDE EFFECTS MAY BE MANAGED

Buserelin • Abdominal pain • Your cardiac function and blood pressure will be monitored
(Suprefact SPC, • Arthralgia before, during and after treatment
2015) • Blood pressure changes • Let your doctor know if you experience arthralgia, myalgia,
• Bowel changes rash or fluid retention/swelling (oedema) – they will help you to
• Breast swelling manage these side effects
• Fatigue
• Heart palpitations • Gastrointestinal effects such as constipation, nausea
and abdominal pain should be reported to your doctor
• Hot flushes
• Loss of sex drive • Your doctor may be able to help you cope with hormonal
• Myalgia effects such as hot flushes, breast swelling and loss of sex
• Nausea drive
• Nose irritation
• Oedema
• Rash
• Weight gain

Degarelix • Hot flushes • Let your doctor know if you experience any burning or skin
(Firmagon SPC, • Injection site reactions changes at the injection site, so that they can decide how to
2017) manage these
• Your doctor may be able to help you cope with hormonal effects
such as hot flushes

Enzalutamide • Fatigue • Your blood pressure will be monitored before, during and
(Xtandi SPC, 2018 • Headache after treatment
• Hot flush • Let your doctor know if you experience fatigue or headaches –
• Hypertension they will help you to manage these side effects
• Your doctor may be able to help you cope with hormonal
effects such as hot flushes and headaches

Flutamide • Breast pain, • Gastrointestinal effects such as constipation, nausea and

(Flutamide tenderness and vomiting should be reported to your doctor
SPC, 2017) production of milk • Your doctor may be able to help you cope with hormonal effects
• Diarrhoea such as hot flushes, breast symptoms and sexual problems
• Erection problems
• Hot flushes
• Loss of sex drive
• Nausea/vomiting

Goserelin • Acne • Let your doctor know if you experience any burning or skin
(Zoladex SPC, • Erection problems changes at the injection site, so that they can decide how to
2017) • Hot flushes manage these
• Increased sweating • Your doctor may be able to help you cope with hormonal
• Injection site reactions effects such as hot flushes, sweating, acne and sexual
• Loss of sex drive problems

continued overleaf

35
Prostate cancer

THERAPY POSSIBLE SIDE EFFECT HOW THE SIDE EFFECTS MAY BE MANAGED

Leuprorelin • Bone pain • Let your doctor know if you experience any burning or skin
(Prostap • Erection problems changes at the injection site, so that they can decide how to
SPC, 2018) • Fatigue manage these
• Hot flushes • Let your doctor know if you experience fatigue, myalgia or pain
• Increased sweating – they will help you to manage these side effects
• Injection site reactions
• Loss of sex drive • Your doctor may be able to help you cope with hormonal effects
such as hot flushes, sweating, testicular atrophy and sexual
• Myalgia
problems
• Testicular atrophy
• Weight changes

Triptorelin • Loss of sex drive • Let your doctor know if you experience asthenia, paraesthesia
(Decapeptyl SPC, • Lower limb (a prickling sensation) or pain – they will help you to manage
2016) paraesthesia these side effects
• Hot flushes • Your doctor may be able to help you cope with hormonal
• Increased sweating effects such as hot flushes, sweating and sexual problems
• Back pain
• Erection problems
• Asthenia

Important side effects associated with individual hormone therapy drugs used in the treatment of prostate
cancer. The most recent Summary of Product Characteristics (SPC) for any individual drug can be located at:
http://www.ema. europa.eu/ema/.

Chemotherapy
Side effects from chemotherapy vary depending upon the drugs and the doses used – you may get some
of those listed below but you are very unlikely to get all of them. Youmay also experience some side effects
that are not listed below. The main areas of the body affected by chemotherapy are those where new cells
are being quickly made and replaced (bone marrow, hair follicles, the digestive system, the lining of
your
mouth). Some patients find that their sense of taste is affected – changes in enzymes in your mouth can
lead to a metallic taste and blisters. Reductions in your levels of neutrophils (a type of white blood cell) can
lead to neutropenia, which can make you more susceptible to infections. Most side effects of
chemotherapy are temporary and can be controlled with drugs or lifestyle changes – your doctor will help
you to manage them (Macmillan, 2016). The table below lists the most common side effects of chemotherapy
drugs that may be used in the treatment of prostate cancer.

36
 ESMO Patients Guide

CHEMOTHER POSSIBLE SIDE EFFECT HOW THE SIDE EFFECTS MAY BE MANAGED
APY DRUG
Docetaxel • Alopecia • Your blood cell counts will be monitored frequently throughout
(Taxotere SPC, • Anaemia your treatment in order to detect any neutropenia, anaemia
2016) • Anorexia or thrombocytopenia – your doctor may adjust your
• Asthenia treatment according to test results and will advise you on how
• Diarrhoea to prevent infections
• Extravasation-related • Report any signs of peripheral neuropathy to your doctor,
tissue damage who will help you to manage this side effect
• Increased infections
• Effects on the gastrointestinal system (nausea, vomiting,
• Nail disorders
diarrhoea) and stomatitis may result in loss of appetite
• Nausea
(anorexia) or feelings of weakness (asthenia). Your doctor will
• Neutropenia
be able to help you to prevent or manage these side effect
• Oedema
• Peripheral • Let your doctor know if you experience any nail changes, skin
neuropathy reactions or fluid retention/swelling (oedema) – they will help
• Skin reaction you to manage these side effects
• Stomatitis • Alopecia can be upsetting for many patients; your doctor will
• Thrombocytopenia provide you with information on how to cope with this side
• Vomiting effect. Some hospitals can provide cold caps to reduce hair
loss
• Let your doctor know if you experience any burning or skin
changes at the injection site, so that they can decide how to
manage these. Many extravasations cause very little damage,
but you may need to be treated with an antidote and apply
compresses to the area for a few days (Pérez Fidalgo et al., 2012)

Cabazitaxel • Abdominal pain • Your blood cell counts will be monitored frequently throughout
(Jevtana • Alopecia your treatment in order to detect any neutropenia, anaemia,
SPC, 2017) • Anaemia leukopenia or thrombocytopenia – your doctor may adjust
• Anorexia your treatment according to test results and will advise you on
• Arthralgia how to prevent infections
• Asthenia • Effects on the gastrointestinal system (constipation, nausea,
• Back pain vomiting, diarrhoea, taste changes) may result in loss of appetite
• Constipation (anorexia) or feelings of weakness (asthenia). Your doctor or
• Cough nurse will be able to help you to prevent or manage these side
• Diarrhoea effects
• Dyspnoea
• Let your doctor or nurse know if you experience a persistent
• Fatigue
cough. Troublesome dyspnoea can be treated with drugs called
• Fever
opioids or benzodiazepines, and in some cases, steroids are
• Haematuria
used (Kloke and Cherny, 2015)
• Leukopenia
• Nausea/vomiting • Let your doctor or nurse know if you experience arthralgia or
• Neutropenia pain and they will help you to manage these side effects
• Taste changes (metallic, • Alopecia can be upsetting for many patients; your doctor will
salty or bitter tastes) provide you with information on how to cope with this side
• Thrombocytopenia effect. Some hospitals can provide cold caps to reduce hair
loss

Important side effects associated with individual chemotherapy drugs used in the treatment of prostate
cancer. The most recent Summary of Product Characteristics (SPC) for any individual drug can be located at:
http://www.ema. europa.eu/ema/.

37
Prostate cancer

Other treatments
Supportive therapy with bisphosphonates such as zoledronic acid can result in side effects including
flu-like symptoms, renal toxicity and low calcium levels. Bisphosphonates can also occasionally lead
to
osteonecrosis (death of bone tissues) in the jaw. Although this is very rare, it is important that you clean
your teeth regularly and carefully and report any oral problems to your doctor and dentist. Denosumab
therapy
can also potentially lead to osteonecrosis of the jaw, as well as low calcium levels and skin infections.
It is very important that you inform your doctor or nurse well in advance of any planned dental
treatments, as bisphosphonates and denosumab therapy will have to be temporarily stopped.

38
 ESMO Patients Guide

What happens
next?
Follow-up
appointments

You will be able to discuss any concerns you have

at your follow-up appointments

Whether you have had curative treatment or are

receiving long-term hormone therapy, your doctor will
arrange follow-up appointments. During these
appointments,
you will typically have a blood test to monitor your PSA
level. Depending on your PSA level, you might also
have a digital rectal examination. Patients whoare
on
long-term hormone therapy may have scans to check
for
osteoporosis – your doctor will discuss this with you.
Your doctor will let you know how often you need to return
for further follow-up appointments, but a typical follow-up
schedule after curative treatment would involve check-
ups
every 6 months in the first 2 years after treatment, then
every 12 months after that.

Looking after your health

After you have had treatment for prostate cancer, you may feel very tired and emotional. Give your body time
to recover and make sure you get enough rest, but there is no reason to limit activities if you are feeling well.
It is important to take good care of yourself and get the support that you need.
• Take plenty of rest when you need it: Give your body time to recover. Complementary
therapies, such as aromatherapy, may help you relax and cope better with side effects. Your hospital
may offer complementary therapy; ask your doctor for details.
• Eat well and keep active: Eating a healthy diet and keeping active can help improve your fitness. It
is important to start slowly, with gentle walking, and build up as you start to feel better. Vitamin D,
which the body needs to absorb calcium, is very important for men having hormone therapy
because of the risk of osteoporosis. We mainly get vitamin D from sunlight and some foods, but
your doctor may also recommend that you take a daily supplement.

39
Prostate cancer

The following eight recommendations form a good foundation for a healthy lifestyle after cancer (Wolin et al.,
2013):

• Don’t smoke.
• Avoid second-hand smoke.
• Exercise regularly.
• Avoid weight gain.
• Eat a healthy diet.
• Drink alcohol in moderation (if at all).
• Stay connected with friends, family and other cancer survivors.
• Attend regular check-ups and screening tests.

A healthy, active lifestyle will help you to recover

physically and mentally

Regular exercise is an important part of a healthy lifestyle,

helping you to keep physically fit and avoid weight gain.
This is particularly important for men with prostate
cancer, as studies have shown that an exercise training
programme can reduce the side effects of long-term
androgen deprivation therapy and improve quality of
life (Bourkeet al., 2018). It is very important that you listen
carefully to the recommendations of your doctor or nurse,
and talk to them about any difficulties you have with
exercise.

Long-term effects
After completing treatment for prostate cancer, you may experience some long-term side effects, depending on
the treatment you have received.
Long-term side effects of surgery for prostate cancer may follow on from the short-term effects, including
permanent erection problems and urinary incontinence. The long-term effects of hormone therapy for
prostate cancer can include weight gain, loss of stamina, mood swings, osteoporosis and heart
problems. Radiotherapy for prostate cancer may cause irritation of the rectum (proctitis) or the
bladder (cystitis), leading to more frequent toilet visits and possibly bleeding (Dearnaley et al., 2007). There
may also be an increase in erection problems from 1–2 years after radiotherapy treatment. There is a
theoretical possibility that radiotherapy could cause cancers in other organs around the treatment area,
however this has not been proven in men treated for prostate cancer.
The long-term effects of prostate cancer treatment on your sex life can be difficult to come to terms with.
Talking to your partner about your sexual difficulties can help, or it may help to talk to a close friend if you are
not

40
 ESMO Patients Guide

in a relationship. A penile rehabilitation programme

can provide ways to adapt to the changes in your sexual
function, and counsellors or therapists can help with anxiety
about your sex life – talk to your doctor or nurse to find
out what help is available in your area.
The long-term effects of prostate cancer and its treatment
can bemanaged so it is important that you tell your doctor
or nurse about any persistent or new symptoms. Your doctor
or nurse will also work with you to develop a personalised
survivorship care plan.
For further information and advice regarding how to regain your life as far as possible after treatment for cancer, see
ESMO’s patient guide on survivorship (http://www.esmo.org/Patients/Patient-Guides/Patient-Guide-on-Survivorship).

Survivorship

What does
survivorship mean?

Let us explain
it to you.

In collaboration with
ESMO Patient Guide Series
based on the ESMO Clinical Practice Guidelines
esmo.org

Emotional support
It is common to be overwhelmed by your feelings when
you have been diagnosed with cancer and when you have
been through treatment. If you feel anxious or depressed,
talk
to your doctor or nurse – they can refer you to a specialist
counsellor or psychologist who has experience of dealing
with emotional problems of people dealing with cancer. It
may also help to join a support group so that you can talk to
other people who understand exactly what you are going
through.

41
Prostate cancer

Support groups
In Europe, there are patient advocacy groups, which help
patients and their families to navigate the prostate cancer
landscape. They can be local, national or international,
and they work to ensure patients receive appropriate and
timely care and education. These groups can provide you
with
the tools you may need to help you better understand
your disease, and to learn how to cope with it, living the
best quality of life that you can.
Europa Uomo is a European coalition of patient support
groups for prostate cancer. It was established in 2004
and works to increase awareness of prostate cancer in
Europe.
For further information about Europa Uomo visit: https://
www.europa-uomo.org/

42
 ESMO Patients Guide

References
Bourke L, Turner R, Greasley R, et al; STAMINA investigators. A multi-centre investigation of delivering national
guidelines on exercise training for men with advanced prostate cancer undergoing androgen deprivation
therapy in the UK NHS.PLoS One 2018;13(7):e0197606.
Cancer.Net. 2017. Fatigue. Available from: http://www.cancer.net/navigating-cancer-care/side-effects/fatigue.
Accessed 10th September 2018.
Cherny NI; ESMO Guidelines Working Group. ESMO Clinical Practice Guidelines for the management of
refractory symptoms at the end of life and the use of palliative sedation. Ann Oncol 2014;25(Suppl 3):iii143–
iii152.
Clarke N, Wiechno PJ, Alekseev B, et al. Olaparib combined with abiraterone in patients (pts) with metastatic
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5003.
ClinicalTrials.gov. 2017. Learn about clinical studies. Available from: https://clinicaltrials.gov/ct2/about-studies/
learn. Accessed 10th September 2018.
Dearnaley DP, Sydes MR, Langley RE, et al. The early toxicity of escalated versus standard dose conformal
radiotherapy with neo-adjuvant androgen suppression for patients with Localised prostate cancer: results
from the MRC RT01 trial (ISRCTN47772397). Radiother Oncol 2007;83(1):31-41.
De Bono JS, Goh JCH, Ojamaa K, et al. KEYNOTE-199: Pembrolizumab (pembro) for docetaxel-
refractory metastatic castration-resistant prostate cancer (mCRPC). J Clin Oncol 2018;36(Suppl):Abstr
5007.
Escamilla DM and Jarrett P. The impact of weight loss on patients with cancer. Nurs Times
2016;112(11):20–22.
ESMO Guidelines Committee.Appendix 1: Cancer of the Prostate: eUpdate published online 28 September 2017.
Ann Oncol 2018;29(Suppl 4):iv256.
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Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research
on Cancer. Available from: http://globocan.iarc.fr. Accessed 10th September 2018.
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the KEYNOTE-028 study. Ann Oncol 2018;29(8):1807–1813.
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Prostate cancer

GLOSSARY
ABIRATERONE BISPHOSPHONATES
A hormone therapy that inhibits testosterone synthesis Drugs that help prevent, or slow down, osteoporosis, and
by blocking an enzyme called cytochrome p17 prevent broken bones and other bone problems caused by
bone metastases; also used in adjuvant treatment
ACTIVE SURVEILLANCE
A treatment plan that involves closely watching a BONE MARROW
patient’s condition but not giving any treatment unless A spongy tissue found inside some bones (e.g. hip and
there are changes in test results that show the condition thigh bones). It contains stem cells, which are cells that
is getting worse can develop into red blood cells, white blood cells or
platelets
ADENOCARCINOMA
Cancer that begins in glandular (secretory) cells BRACHYTHERAPY
A type of radiotherapy in which the radioactive source
ADJUVANT (TREATMENT) is placed directly into or near a tumour
Additional treatment given after the primary treatment
to reduce the chance of the cancer coming back BRCA1
A gene that normally controls tumour growth but when
ALOPECIA mutated has the opposite effect
Hair loss
BRCA2
ANAEMIA A gene that normally controls tumour growth but when
A condition in which there is a shortage of red blood mutated has the opposite effect
cells or haemoglobin (a protein in red blood cells that
carries oxygen throughout the body) BUSERELIN
A luteinising hormone-releasing hormone agonist
ANDROGEN DEPRIVATION THERAPY that blocks the production of testosterone in the
Treatment to suppress or block the production or action testicles
of male hormones
CABAZITAXEL
ANOREXIA A type of chemotherapy that is administered through a
A lack or loss of appetite drip into a vein in your arm or chest
ANTI-ANDROGEN (THERAPY) CADMIUM
Treatment with drugs that block the action of male A metal that is a by-product of zinc refining and is used
hormones in the body to make batteries, pigments and plastics. It is also
ANTIBIOTIC found in tobacco and tobacco smoke
A type of drug used to treat and prevent bacterial CASTRATION-RESISTANT PROSTATE CANCER
infections (CRPC)
ARTHRALGIA Prostate cancer that is no longer responsive to
Joint pain castration treatments (i.e. reduction of androgen/
testosterone by surgical or medical treatment)
ASTHENIA
CHEMOTHERAPY
Abnormal feeling of weakness or lack of energy
A type of cancer treatment using medicine that kills the
BENIGN PROSTATIC HYPERPLASIA cancer cells by damaging them, so that they cannot
A benign (not cancerous) condition in which an reproduce and spread
overgrowth of prostate tissue pushes against the
CLINICAL TRIAL
urethra and the bladder, blocking the flow of urine
A study that compares the effects of one treatment
BICALUTAMIDE with another
An anti-androgen drug that prevents testosterone
COLD CAP
from reaching cancer cells
A cap that cools the scalp before, during and after
BIOPSY treatment to reduce the effects of the treatment on
A medical procedure in which a small sample of cells or hair follicles
tissue is taken for examination under a microscope

44
 ESMO Patients Guide

GLOSSARY
COMPUTED TOMOGRAPHY (CT) SCAN EXTERNAL SPHINCTER
A scan using x-rays and a computer to create detailed A muscle encircling the outside wall of the anal opening
images of the inside of your body
EXTRAVASATION
CONCURRENT Leakage of fluid, such as an anti-cancer drug, from a
At the same time blood vessel or tube into the tissue around it
CURATIVE (TREATMENT) FATIGUE
A treatment that is intended to cure the cancer Overwhelming tiredness
CYSTITIS FLUTAMIDE
Inflammation of the lining of the bladder An anti-androgen drug that prevents testosterone
from reaching cancer cells
CYTOCHROME P17
An enzyme that the testicles need to produce GASTROINTESTINAL (SYSTEM)
testosterone The system of organs responsible for getting food into
and out of the body and for making use of food to keep
DEGARELIX the body healthy – includes the oesophagus, stomach
A gonadotrophin-releasing hormone antagonist that and intestines
blocks the production of testosterone in the testicles
GENES
DENOSUMAB Pieces of DNA responsible for making substances that
A drug used to treat osteoporosis and prevent broken the body needs to function
bones and other bone problems caused by bone
metastases GLAND
An organ that makes one or more substances, such as
DIGITAL RECTAL EXAMINATION hormones, digestive juices, sweat, tears, saliva or milk
An examination in which a doctor or nurse inserts a
lubricated, gloved finger into the rectum to feel for GLEASON SCORE
abnormalities A system of grading prostate cancer tissue based on
how it looks under a microscope. A low Gleason score
DNA means the cancer tissue is similar to normal prostate
Deoxyribose nucleic acid, the chemical that carries tissue and the tumour is less likely to spread; a high
genetic information in the cells of your body Gleason score means the cancer tissue is very different
DOCETAXEL from normal and the tumour is more likely to spread
A type of chemotherapy that is administered through a GONADOTROPHIN-RELEASING HORMONE ANTAGONIST
drip into a vein in your arm or chest A drug that blocks the pituitary gland from making
DUCTS hormones called follicle-stimulating hormone and
Tubes or vessels in the body that fluids pass through luteinising hormone. In men, this causes the testicles to
stop making testosterone
DYSPNOEA
Shortness of breath GOSERELIN
A luteinising hormone-releasing hormone agonist
ENZALUTAMIDE that blocks the production of testosterone in the
An anti-androgen drug that prevents testosterone testicles
from reaching cancer cells
HAEMATURIA
ENZYME Blood in the urine
A protein that speeds up chemical reactions in the body
HAIR FOLLICLE
EXTERNAL BEAM RADIOTHERAPY A small sac in the skin from which hair grows
A type of radiotherapy that uses a machine to aim high-
HORMONE
energy rays at the cancer from outside of the body
A substance made by glands in the body. Hormones
circulate in the bloodstream and control the actions of
certain cells or organs

45
Prostate cancer

GLOSSARY
HORMONE-REFRACTORY PROSTATE CANCER (HRPC) LOCALISED (PROSTATE CANCER)
Prostate cancer that is no longer responsive to Cancer that is completely contained within the prostate
castration treatments (i.e. reduction of androgen/ gland and has not spread anywhere else in the body
testosterone by surgical or medical treatment). This
term has now been replaced by castration-resistant LOCALLYADVANCED (PROSTATE CANCER)
prostate cancer or CRPC Cancer that has spread from where it started to nearby
tissue or lymph nodes
HORMONE THERAPY
Treatments that block the actions of testosterone LYMPHATIC SYSTEM
A network of tissues and organs that help rid the body
HYPERTENSION of toxins, waste and other unwanted materials. The
Abnormally high blood pressure primary function of the lymphatic system is to
transport lymph, a fluid containing infection-fighting
HYPOKALAEMIA white blood cells, throughout the body
An abnormally low level of potassium in the blood
LYMPH NODES
IONISING RADIATION Small structures throughout the lymphatic system that
Any type of particle or electromagnetic wave that work as filters for harmful substances, such as cancer
carries enough energy to ionise or remove electrons cells or bacteria
from an atom (e.g. x-rays)
LYMPHOEDEMA
IMMUNOTHERAPY Swelling caused by a build-up of lymph fluid in the
A type of cancer treatment that stimulates the body’s tissues of the body. This may result from damage to the
immune system to fight the cancer lymphatic system because of surgery or radiotherapy
INSULIN-LIKE GROWTH FACTOR 1 (IGF-1) to the lymph nodes in the pelvis
A protein that stimulates the growth of many types of MARGIN
cells The edge or border of the tissue removed in cancer
KEYHOLE SURGERY surgery. The margin is described as negative or clean
Minimally invasive surgery carried out through a very when no cancer cells are found at the edge of the tissue,
small incision, with special instruments suggesting that all of the cancer has been removed.
The margin is described as positive or involved when
LEUKOPENIA cancer cells are found at the edge of the tissue,
A decrease in the number of leukocytes (a type of white suggesting that all of the cancer has not been
blood cell) in the blood, which places individuals at removed
increased risk of infection
METASTASES
LEUPRORELIN Cancerous tumours that have originated from a
A luteinising hormone-releasing hormone agonist primary
that blocks the production of testosterone in the tumour/growth in another part of the body
testicles
METASTATIC (PROSTATE CANCER)
LUTEINISING HORMONE-RELEASING HORMONE A cancer that has spread from its (primary) site of
AGONIST origin to different parts of the body
A drug that keeps the testicles from making
MAGNETIC RESONANCE IMAGING (MRI) SCAN
testosterone by blocking other hormones that are
needed to make it A type of scan that uses strong magnetic fields and
radio waves to produce detailed images of the inside
LEVATOR MUSCLES of the body
Muscles on either side of the pelvis
MULTIDISCIPLINARY TEAM
LOCAL ANAESTHETIC A group of healthcare workers who are members of
A medication that causes reversible absence of pain different disciplines (e.g. oncologist, nurse specialist,
sensation around the site of administration physiotherapist, radiologist) and provide specific
services to the patient. The activities of the team are
brought together using a care plan

46
 ESMO Patients Guide

GLOSSARY
MUTATION PARAESTHESIA
A permanent alteration in the DNA sequence that makes An abnormal sensation, such as burning or prickling
up a gene, such that the sequence differs from what is
found in most people PELVIC LYMPHADENECTOMY
Surgery to remove lymph nodes in the pelvis
MYALGIA
Muscular pain PELVIC NODE DISSECTION
A procedure to remove pelvic lymph nodes to see if
NEOADJUVANT (TREATMENT) they contain cancerous cells
Treatment given as a first step to shrink a tumour
before the main treatment is given PEMBROLIZUMAB
A type of immunotherapy that blocks a protein
NERVE-SPARING PROSTATECTOMY called
Removal of prostate tissue without removing the PD-1 on the surface of certain immune cells called
nerves that control erections T-cells; this activates the T-cells to find and kill cancer
cells. It is administered through a drip into a vein in
NEUROENDOCRINE CANCER your arm or chest
Cancer that forms from cells that release hormones
into the blood in response to a signal from the nervous PENILE REHABILITATION PROGRAMME
system A programme of treatment for sexual problems following
prostate cancer treatment, including counselling and sex
NEUTROPENIA therapy, medication and lifestyle advice
An abnormally low level of neutrophils in the blood,
which increases risk of infection PERINEUM
The area of skin between the anus and scrotum in
NEUTROPHILS males
A type of white blood cell that play an important role in
fighting off infection PERIPHERAL NEUROPATHY
Damage to the nerves in the extremities of the body.
OEDEMA Symptoms may include pain, sensitivity, numbness or
A build-up of fluid in the body which causes the affected weakness in the hands, feet or lower legs
tissues to become swollen
POSITRON EMISSION TOMOGRAPHY (PET)
OLAPARIB An imaging test that uses a dye with radioactive
A drug used to treat some types of cancer caused by tracers, which is injected into a vein in your arm
mutations in the BRCA1 and BRCA2 genes
PROCTITIS
OSTEONECROSIS Inflammation of the lining of the rectum
Loss of blood flow to bone tissue, causing the bone to die
PROGNOSIS
OSTEOPOROSIS The likely outcome of a medical condition
A decrease in the amount and thickness of bone tissue,
which causes the bones to become weak and break PROGRAMMED CELL DEATH PROTEIN 1 (PD-1)
more easily A cellular protein thought to be involved in helping the
tumour to evade detection by the body’s immune system
PALLIATIVE (CARE)
The care of patients with advanced, progressive illness. PROSTATE
It focuses on providing relief from pain, symptoms and A gland in the male reproductive system. The prostate
physical and emotional stress, without dealing with the surrounds the part of the urethra just below the bladder,
cause of the condition and produces a fluid that forms part of the semen
PALPABLE PROSTATE-SPECIFIC ANTIGEN (PSA)
Can be felt by touch A protein made by the prostate gland and found in
the blood
PALPITATIONS
A rapid or irregular heartbeat RADICAL PROSTATECTOMY
Surgery to remove the entire prostate and some of the
tissue around it

47
Prostate cancer

GLOSSARY
RADIOACTIVE/RADIOACTIVITY THROMBOCYTOPENIA
A material that is unstable and spontaneously emits A decrease in platelets in the blood. This causes
energy (radiation) bleeding into the tissues, bruising, and slow blood
clotting after injury
RADIOTHERAPY
Treatment involving the use of high-energy radiation, TRANSRECTAL ULTRASOUND SCAN GUIDED (TRUS)
which is commonly used to treat cancer BIOPSY
A procedure used to diagnose prostate cancer. An
RADIUM-223 ultrasound scanner is inserted into the rectum to
A radioactive liquid used to treat prostate cancer that produce a clear picture of the prostate gland and a
has spread to the bone needle is used to take samples of tissue from the
RECURRENCE prostate gland
Return of a cancer TRANSURETHRAL RESECTION OF THE
RECTUM PROSTATE
Back passage Removal of the inner part of the prostate gland

RENAL TRIPTORELIN
Relating to the kidneys A luteinising hormone-releasing hormone agonist
that blocks the production of testosterone in the
RISK FACTOR testicles
Something that increases the chance of developing a
disease TUMOUR
A lump or growth of abnormal cells. Tumours may be
SCROTUM benign (not cancerous) or malignant (cancerous). In
The external sac that contains the testicles this guide, the term ‘tumour’ refers to a cancerous
growth, unless otherwise stated
SEMEN
The fluid that is released through the penis during ULTRASOUND
ejaculation. Semen is made up of sperm from the testicles A type of medical scan where sound waves are
and fluid from the prostate and other sex glands converted into images by a computer

SEMINAL VESICLES URETHRA

Glands that help produce semen The tube through which urine leaves the body

SILDENAFIL URINARY INCONTINENCE

A drug used to treat erection problems Inability to control the flow of urine from the
bladder
STEROID
A type of drug used to relieve swelling and URINARY TRACT
inflammation. Some steroid drugs also have anti- The organs of the body that produce and discharge
tumour effects urine, including the kidneys, ureters, bladder and
urethra
STOMATITIS
Inflammation of the inside of the mouth WATCHFUL WAITING
Closely watching a patient’s condition but not giving
TESTICULAR ATROPHY treatment unless symptoms appear or change
A condition in which the testicles become smaller
X-RAY
TESTOSTERONE An imaging test, using a type of radiation that can pass
A hormone made mainly in the male reproductive through the body, which allows your doctor to see
system that is needed to develop and maintain male images of inside your body
sex characteristics
ZOLEDRONIC ACID
A type of bisphosphonate used to treat cancers that
have spread to the bone

48
 ESMO Patients Guide

This guide has been prepared to help you, your friends and your family better understand the nature of prostate
cancer and the treatments that are available. The medical information described in this document is based
on the clinical practice guidelines of the European Society for Medical Oncology (ESMO) for the management
of prostate cancer. We recommend that you ask your doctor about the tests and types of treatments available
in your country for your type and stage of prostate cancer.

This guide has been written by Kstorfin Medical Communications Ltd on behalf of
ESMO.
© Copyright 2018 European Society for Medical Oncology. All rights reserved
worldwide. European Society for Medical Oncology (ESMO)
Via Ginevra 4
6900 Lugano
Switzerland
Tel: +41 (0)91
973 19 99
Fax: +41
(0)91 973 19
02
E-mail:
clinicalguideli
nes@esmo.
org 49
We can help you understand prostate cancer
and the available treatment options.

The ESMO Guides for Patients are designed to assist patients, their
relatives and caregivers to understand the nature of different types of cancer
and evaluate the best available treatment choices. The medical information
described in the Guides for Patients is based on the ESMO Clinical
Practice Guidelines, which are designed to guide medical oncologists
in the diagnosis, follow-up and treatment in different cancer types.

For more information, please visit www.esmo.org